The bundle "plus": the effect of a multidisciplinary team approach to eradicate central line-associated bloodstream infections

UMMS Affiliation

Department of Anesthesiology; Department of Medicine, Division of Infectious Diseases and Immunology; Department of Quantitative Health Sciences

Publication Date


Document Type



Bacteremia; Catheter-Related Infections; Catheterization, Central Venous; Central Venous Catheters; Chlorhexidine; Critical Care; Critical Illness; Hand Hygiene; Humans; Intensive Care Units; Interdisciplinary Communication; Patient Care Team; Regression Analysis; Staphylococcal Infections; Staphylococcus


Anesthesiology | Clinical Epidemiology | Health Services Administration | Infectious Disease


BACKGROUND: Central line-associated bloodstream infections (CLABSIs) have decreased significantly over the last decade. Further reductions in CLABSI rates should be possible. We describe a multidisciplinary approach to the reduction of CLABSIs.

METHODS: This was an observational study of critically ill patients requiring central venous catheters in 8 intensive care units in a tertiary medical center. We implemented a catheter bundle that included hand hygiene, education of providers, chlorhexidine skin preparation, use of maximum barrier precautions, a dedicated line cart, checklist, avoidance of the femoral vein for catheter insertion, chlorhexidine-impregnated dressings, use of anti-infective catheters, and daily consideration of the need for the catheter. Additional measures included root cause analyses of all CLABSIs, creation of a best practice atlas for internal jugular catheters, and enhanced education on blood culture collection. Data were analyzed using the Poisson test and regression.

RESULTS: CLABSI, catheter use, and microbiology were tracked from 2004 to 2012. There was a 92% reduction in CLABSIs (95% lower confidence limit: 67.4% reduction, P < 0.0001). Central venous catheter use decreased significantly from 2008 to 2012 (P = 0.032, -151 catheters per year, 95% confidence limits: -277 to -25), whereas peripherally inserted central catheter use increased (P = 0.005, 89 catheters per year, 95% confidence limits: 50 to 127). There was no apparent association between unit-specific Acute Physiology And Chronic Health Evaluation III/IV scores and CLABSI. Three units have not had a CLABSI in more than a year. The most common organism isolated was coagulase-negative staphylococcus. Since the implementation of minocycline/rifampin catheters, no cases of methicillin-resistant Staphylococcus aureus CLABSI have occurred.

CONCLUSIONS: The implementation of a standard catheter bundle combined with chlorhexidine dressings, minocycline/rifampin catheters, and other behavioral changes was associated with a sustained reduction in CLABSIs.

DOI of Published Version



Walz JM, Ellison RT 3rd, Mack DA, Flaherty HM, McIlwaine JK, Whyte KG, Landry KE, Baker SP, Heard SO; CCOC Research Group. The bundle "plus": the effect of a multidisciplinary team approach to eradicate central line-associated bloodstream infections. Anesth Analg. 2015 Apr;120(4):868-76. doi:10.1213/ANE.0b013e3182a8b01b. PubMed PMID: 24149581.

Journal/Book/Conference Title

Anesthesia and analgesia

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